The Prevalence of Natural Health Product Use in Patients with Acute Cardiovascular Disease

Background: Natural health products (NHP) use may have implications with respect to adverse effects, drug interactions and adherence yet the prevalence of NHP use by patients with acute cardiovascular disease and the best method to ascertain this information is unknown. Objective: To identify the best method to ascertain information on NHP, and the prevalence of use in a population with acute cardiovascular disease. Methods: Structured interviews were conducted with a convenience sample of consecutive patients admitted with acute cardiovascular disease to the University of Alberta Hospital during January 2009. NHP use was explored using structured and open-ended questions based on Health Canada’s definition of NHP. The medical record was reviewed, and documentation of NHP use by physicians, nurses, and pharmacists, compared against the gold-standard structured interview. Results: 88 patients were interviewed (mean age 62 years, standard deviation [SD 14]; 80 % male; 41 % admitted for acute coronary syndromes). Common co-morbidities included hypertension (59%), diabetes (26%) and renal impairment (19%). NHP use was common (78 % of patients) and 75 % of NHP users reported daily use. The category of NHP most commonly used was vitamins and minerals (73%) followed by herbal products (20%), traditional medicines including Chines

Developing Preceptors through Virtual Communities and Networks: Experiences from a Pilot Project

ABSTRACTBackground: Supporting preceptors is critical to the expansion of experiential learning opportunities for the pharmacy profession. Informal learning opportunities within communities of practitioners are important for hospital preceptors. However, such communities may be limited by geographic separation of preceptors from peers, faculty members, and supports within the pharmacy services department.Objective: To use computer-mediated conferencing to create a sense of community among preceptors, specifically by using this medium to provide initial development of and continuing support for preceptors, and to examine preceptors’ satisfaction with this approach.Methods: Thirty-nine preceptors who had completed a day-long face-to face preceptor development workshop and who were supervising students in 1 of 2 specific rotation blocks were invited to participate in the study. The pharmacists used computer-mediated conferencing to meet for virtual networking about specific topics. They met once before the student rotation to receive instructions about the technology and to discuss student orientation and scheduling, and 3 times during the student rotation for open discussion of specific topics. Evaluation and feedback were solicited by means of an electronic survey and virtual (i.e., computerbased) feedback sessions with an independent facilitator.Results: The response rate was 66% (26/39) for the electronic survey, but only 15% (6/39) for the virtual feedback sessions. All of the respondents were experienced preceptors, but for 92% (22/24), this was their first experience with computer-mediated conferencing. Overall, the sessions had a positive reception, and participants found it useful to share information and experiences with other preceptors. The main challenges were related to the technology, perceived lack of support for their participation in the sessions, and inconvenience related to the timing of sessions.Conclusion: Computer-mediated conferencing allowed preceptors to learn from and to support each other despite geographic distance. The participants felt that these sessions encouraged them to serve as preceptors regularly. Such encouragement could contribute to the retention of preceptors, which is important to the expansion of experiential learning.RÉSUMÉContexte : Le soutien des précepteurs est essentiel à l’expansion des occasions d’apprentissage par l’expérience pour la profession de pharmacien. Les occasions d’apprentissage informel au sein des collectivités de praticiens sont importantes pour les précepteurs hospitaliers. En revanche, de telles collectivités peuvent être limitées, car certains précepteurs sont géographiquement séparés de leurs pairs, des membres du corps professoral et du soutien au sein des services de pharmacie.Objectif : Recourir aux outils de téléconférence assistée par ordinateur pour créer un sentiment d’appartenance à une collectivité parmi les précepteurs, plus particulièrement en utilisant ces outils comme moyen de perfectionnement initial et de soutien continu des précepteurs, et évaluer la satisfaction des précepteurs relativement à cette approche.Méthodes : On a invité à participer à cette étude 39 précepteurs qui avaient terminé un atelier d’une journée en face en face sur le perfectionnement des précepteurs et qui supervisaient des étudiants dans une des deux périodes de stage définies. Les pharmaciens ont utilisé la téléconférence assistée par ordinateur pour des rencontres virtuelles sur des sujets précis. Ils se sont rencontrés une fois avant le stage des étudiants our recevoir des instructions sur la technologie utilisée et discuter de l’orientation des étudiants et de la programmation de leur stage, puis à trois reprises durant le stage des étudiants pour des discussions ouvertes sur des sujets précis. On a sollicité l’évaluation et la rétroaction des précepteurs au moyen d’un sondage électronique et de séances de rétroaction virtuelles avec un animateur indépendant.Résultats : Le taux de réponse au sondage électronique était de 66 % (26/39) et de seulement 15 % (6/39) pour les séances de rétroaction virtuelles. Tous les répondants étaient des précepteurs expérimentés, mais il s’agissait d’une première expérience de la téléconférence assistée par ordinateur pour 92 % (22/44) d’entre eux. Globalement, les séances ont été reçues positivement et les participants ont trouvé utile de pouvoir partager information et expériences avec d’autres précepteurs. Les principales difficultés étaient liées à la technologie, à l’absence apparente de soutien pour leur participation aux séances et aux inconvénients associés au moment choisi pour la tenue des séances.Conclusion : La téléconférence assistée par ordinateur a permis aux précepteurs de profiter d’un apprentissage réciproque et d’un soutien mutuel malgré la distance. Les participants étaient d’avis que ces séances les encourageaient à s’investir dans le préceptorat sur une base régulière. Cet encouragement pourrait contribuer à la rétention des précepteurs, ce qui est important pour l’expansion de l’apprentissage par expérience

Fostering Relationships between Clinicians and Faculties of Pharmacy

INTRODUCTION Increasingly, faculties of pharmacy in Canada comprise 2 types of academic personnel in both tenure and nontenure streams: traditional and practicebased. Practice-based faculty members may be either tenured or nontenured, are involved in teaching, and may or may not have research responsibilities. The focus of practice-based faculty members, who have teaching, research, and clinical responsibilities, is often different from that of traditional faculty members, who have only teaching and research responsibilities. Hence, conflicts regarding the direction of the faculty’s curriculum or research programs and the workload, performance appraisal, promotion, and perceived contribution of individual faculty members may arise. The situation is further complicated because many practice-based faculty members work only part-time in the university, an uncommon scenario for traditional academics. Almost all faculties of pharmacy face these issues. Anecdotal evidence suggests that relationships between these 2 types of academics need to be explicitly nurtured and developed. Improving communications certainly seems an appropriate strategy, with explicit discussion about the issues from all perspectives, especially regarding performance appraisal and promotion. To initiate such a discussion, a one-day session was arranged during the joint meeting of the Association of Faculties of Pharmacy of Canada (AFPC) and the Canadian College of Clinical Pharmacy (CCCP). The goal of this meeting was to establish dialogue between practice-based and traditional faculty members about the roles and responsibilities of the various clinical appointments. In preparation for the meeting a list of several points for discussion was created. These points were circulated to members of both AFPC and CCCP for feedback before the meeting. On the basis of the response of members, 6 specific objectives were selected for discussion at roundtable sessions during the morning of the joint meeting. The specific objectives were as follows:• To identify the pros and cons of tenure-track versus nontenure-track academic appointments for practice-based academic staff.• To identify mechanisms and approaches for including clinical service as one criterion for promotion of nontenure-track practice-based academic staff.• To identify appropriate ranges of responsibility, such as teaching, research, scholarly activity, and clinical service, in consideration of tenure and promotion of tenure-track practice-based academic staff.• To identify how academic and clinical mentoring among practice-based faculty members and preceptors could be improved.• To identify the positive and negative impacts on universities and institutions of clinical crossappointments or joint appointments.• To identify the positive and negative impacts on practice-based faculty members of the possible implementation of the entry-level PharmD degree in Canada.For each objective, several questions were formulated to guide the discussion. Facilitators for the sessions were selected from both AFPC and CCCP and were paired so that one traditional faculty member and one practice-based faculty member facilitated the discussion for each objective. Facilitators either selected their objective on the basis of personal interest or experience or were asked to facilitate a specific objective on the basis of their expertise. The session was held on June 11, 1999, in Quebec City, Quebec. Approximately 60 AFPC members and 150 CCCP members attended the session. During the morning session, attendees were given the opportunity to participate in 3 roundtable sessions, each discussing a different objective. After these discussions, the facilitators met to summarize their findings. These summaries were presented to the participants later in the day. A synopsis of each summary is presented below. Each objective is presented separately, although key points from each of the objectives often overlapped

Structuring an Early Clinical Experience for Pharmacy Students: Lessons Learned from the Hospital Perspective

INTRODUCTIONAlberta Health Services—Edmonton Area is a division of a provincial health authority located in Edmonton, Alberta, serving a population of about 1 million people. It consists of 13 facilities with over 2500 beds, in addition to outpatient clinics and public health offices. Regional Pharmacy Services (RPS), staffed by nearly 180 pharmacists and more than 190 technicians, provides clinical and distribution services. RPS provides a significant proportion of institutional rotation sites for students of the Faculty of Pharmacy and Pharmaceutical Sciences (FPPS) at the University of Alberta. FPPS recently revised the undergraduate curriculum to a modular form and integrated Alberta College of Pharmacists internship hours with FPPS-required experiential training. Until this curricular revision, the first structured hospital experience for undergraduate students did not occur until the final professional year of the program, but a 2-week hospital rotation for second-year pharmacy students has now been added to the curriculum. The first of these rotations was offered in the spring of 2006. The overall goal of this rotation is “to provide the student with an opportunity to participate in the role of the pharmacist in a collaborative and multidisciplinary institutional setting”.1 The objectives and activities of the rotation include understanding patients’ drug-related needs; understanding pharmacists’ legal, ethical, and professional responsibilities; conveying information and recommendations related to drugs and drug use; and learning about drug distribution.1 The development of this rotation posed a number of challenges for RPS, particularly with respect to providing opportunities for students to participate in the pharmacist’s role. Given the modular nature of the curriculum, the students’ therapeutic knowledge base upon completion of their second year is limited to certain areas (Table 1). In addition, the limited duration of the rotation (10 working days) and the requirement to cover some aspects of drug distribution (including medication safety) presented challenges for preceptors accustomed to the 6-week academic rotations of the final year. Finally, because 2006 was the first year for this new academic rotation, the RPS staff members did not have a full understanding of FPPS’s expectations for experiential learning and contribution to patient care during their initial planning. Our goal was to develop and evaluate a new hospital rotation designed to introduce the clinical role of the hospital pharmacist and provide direct patient care experience to secondyear pharmacy students. This report describes our experiences with this rotation and outlines the lessons that we learned

Lessons Learned: A Pilot Program to Cultivate a Clinical Role for Pharmacy Students

INTRODUCTION For many years, first-, second-, and third-year pharmacy students were hired into technical roles for summer employment within the pharmacy department at Capital Health in Edmonton, Alberta. A pilot program to cultivate a clinical role for summer pharmacy students as members of the pharmacy patient care team was undertaken in 2004 by the clinical coordinators (including MLA) at Capital Health. This pilot program was designed to develop a rewarding professional development experience for pharmacy students, to offer meaningful contributions to the pharmacy clinical teams, to positively affect pharmacy students’ views of hospital practice, and to encourage careers in hospital pharmacy. In addition, integrating patient care and professional activities into student positions held promise to initiate change within the department’s culture with respect to students. The role developed for the pilot program was based on clinical pharmacy technician models from the literature, in which the clinical technician provided clinical services support, such as collecting laboratory data, screening patients, taking medication histories, and tracking outcomes, so as to redirect clerical workload and focus pharmacists’ time on direct patient care activities.1-4 These models involved extensive training for specific roles according to established protocols and other clinical tools, as well as assessment of decisionmaking competence for screening tasks.2,4 These previously reported experiences inspired development of a targeted clinical training program at our own institution. In addition, it was felt that a clearly defined role and expectations, supported by targeted training in clinical patient care activities, would promote acceptance of students on the pharmacy clinical team. Capital Health is a regional health authority serving a population of approximately one million. It consists of 13 facilities with a total of more than 2500 beds, in addition to outpatient clinics and public health services. Capital Health provides academic training for the health care professional programs of the University of Alberta. Regional Pharmacy Services, through its nearly 100 pharmacists and more than 65 technicians, provides clinical and distribution services for the health region. In this report we describe our experiences with this pilot program and outline the lessons learned

Non-ST Segment Elevation Myocardial Infarction Associated with IV Infusion of Immunoglobulin

INTRODUCTIONIVimmunoglobulin (IVIG) is used in the treatment of a variety of disorders, including primary and secondary immunodeficiency diseases, Kawasaki disease, and idiopathic thrombocytopenia purpura.1 Although serious adverse cardiovascular reactions are rare, a recent article reviewed 28 published cases of thrombotic complications occurring in association with IVIG administration between 1986 and 2003.2 An additional 36 cases reported recently3-9 were not included in the review. This article describes 2 patients treated in the same month at the authors’ institution for non-ST segment elevation myocardial infarction possibly associated with IVIG administration. To the authors’ knowledge, case 1 represents the first reported case of a patient experiencing non-ST segment elevation myocardial infarction after each of 2 consecutive doses of IVIG

Interactions between Warfarin and Herbal Products, Minerals, and Vitamins: A Pharmacist's Guide

ABSTRACT Objective: To prepare for pharmacists a reference regarding herbal products, minerals, and vitamins with either theoretical or documented interactions with warfarin.Methods: The databases of MEDLINE, EMBASE, and PubMed (for the period January 1966 to June 2000) were searched with the medical subject heading (MeSH) “warfarin” combined with “drug interactions”, “herbal medicine”, and “megavitamin therapy.”Results: The following herbal products have been reported to increase, through various mechanisms, the risk of bleeding when used concomitantly with warfarin: cinchona (quinine), danshen, devil’s claw, dong quai, garlic, ginkgo, ginseng, and papaya (papain). Coenzyme Q10, ginseng, green tea, St John’s wort, and vitamin K decrease the international normalized ratio by a variety of mechanisms. Products with theoretical interactions for which there is no clinical evidence include bromelain, cayenne, echinacea, feverfew, flaxseed, and ginger. Herbal products containing coumarin, coumarin derivatives, and p-coumaric acid, which may potentiate warfarin’s anticoagulant action, are identified in the article. Minerals and vitamins that interact with warfarin are discussed, including iron, magnesium, zinc, and vitamins C, E, and K.Conclusions: Data from case reports, animal studies, and in vitro and in vivo studies serve as information sources for interactions among herbal products, minerals, megavitamins, and warfarin. Limited information is available concerning the onset and extent of an increase or decrease in the international normalized ratio. As such, pharmacists must be diligent and informed about the potential for such interactions and must be ready to serve as proactive patient advocates.RÉSUMÉ Objectif : Préparer à l’intention des pharmaciens un ouvrage de référence sur les produits à base de plantes médicinales, les minéraux et les vitamines et leurs interactions, théoriques ou documentées, avec la warfarine.Méthodes : Des recherches dans les bases de données MEDLINE, EMBASE et PubMed (pour la période allant de janvier 1966 à juin 2000) ont été effectuées à partir du mot pivot (MeSH) «warfarin» et 1) «drug interactions», 2) «herbal medicine» et 3) «megavitamin therapy».Résultats : Des rapports indiquent que les produits à base de plantes médicinales suivants augmentent, par divers mécanismes, le risque de saignement lorsqu’ils sont utilisés en concomitance avec de la warfarine : quinine, Dangshen, griffe du diable, Don Quai, ail, Ginkgo biloba, ginseng, papaïne. Quant aux produits suivants : coenzyme Q10, ginseng, thé vert, vitamine K, millepertuis commun, ils diminuent, aussi par divers mécanismes, le rapport international normalisé. Les produits pour lesquels on a identifié des interactions théoriques mais non prouvées cliniquement sont les suivants : broméline, cayenne, échinacée, grande camomille, graine de lin and gingembre. Les herbes contenant de la coumarine, des coumariniques et de l’acide p-coumarinique, lesquels peuvent potentialiser l’action anticoagulante de la warfarine, sont identifiés dans l’article. Les minéraux et vitamines qui interagissent avec la warfarine y sont également traités, notamment le fer, le magnésium, le zinc et les vitamines C, E et K.Conclusions : Des données issues de rapports de cas, d’études chez les animaux et d’études in vitro et in vivo sont les sources d’information sur les interactions entre la warfarine et les produits à base de plantes médicinales, les minéraux et les mégavitamines. L’information sur le début et l’ampleur de l’augmentation ou de la diminution du rapport international normalisé est toutefois limitée. Par conséquent, les pharmaciens doivent faire preuve de vigilance, être informés à propos de ces interactions potentielles et être prêts à défendre proactivement les intérêts du patient

Anticoagulation Clinics in North America: Operational Insights

ABSTRACTBackground: Although anticoagulation management services have been established since the early 1970s, and reports have consistently confirmed their delivery of high-quality care, little is known about how existing services operate.Objective: To describe the key operational characteristics of anticoagulation management services in North America.Methods: A survey was sent by regular mail to a random sample of anticoagulation management services in the United States (n = 250) and to all Canadian clinics (n = 15). Demographic characteristics, processes of patient care, and quality assurance measures were assessed.Results: Overall, 228 of the 265 clinics were eligible for inclusion and could be reached by mail; of these, 118 (52%) responded to the survey. The clinics were staffed by pharmacists (68% of the clinics [n = 80]), nurses (38% [n = 45]), clerical personnel (26% [n = 31]), physicians (19% [n = 22]), nurse practitioners (10% [n = 12]), and physician assistants (3% [n = 4]). Most of the clinics were operating at maximum capacity, with a median of 300 appointments per month (equally split between in-person and telephone appointments). Referrals originated primarily from physicians, and 47 (40%) of the 118 clinics accepted referrals only for specific indications. The majority of the clinics used algorithms to systematically assess and manage patients (87% [103/118]) and computer systems to document patient care (86% [101/118]). Warfarin dosing algorithms were used by 82% (84/103) of the clinics, and the same proportion (82% [97/118]) performed quality assurance checks. In the event of an adverse outcome, liability was reported to be shared among the referring physician and clinic staff for 48% (57/118) of respondents, whereas 37% (44/118) reported that clinic staff alone would be accountable.Conclusions: To the authors’ knowledge, this is the first survey describing the operational characteristics of anticoagulation management services. Clinic operations were generally consistent with those outlined in consensus guidelines. By providing insight into the daily operations of these services, this study allows recommendations of mechanisms to enhance clinic efficiency.RÉSUMÉContexte : Bien que les services de gestion de l’anticoagulation existent depuis le début des années 1970 et que des rapports aient invariablement confirmé que ces cliniques dispensent des soins de haute qualité, nous en connaissons très peu sur le mode de fonctionnement de ces services.Objectif : Décrire les principales caractéristiques du fonctionnement des services de gestion de l’anticoagulation en Amérique du Nord.Méthodologie : Nous avons envoyé une enquête par courrier à un échantillon aléatoire de services de gestion de l’anticoagulation aux États-Unis (n = 250) et à toutes les cliniques d’anticoagulation du Canada (n = 15). L’enquête évaluait les caractéristiques démographiques, le processus de soins aux patients et les mesures d’assurance de la qualité.Résultats : En général, 228 des 265 cliniques satisfaisaient aux critères de sélection de l’enquête et étaient joignables par courrier; sur ce nombre, 118 (52 %) ont répondu à l’enquête. L’effectif des cliniques se compose de pharmaciens (68 % des cliniques [n = 80]), de personnel infirmier (38 % [n = 45]), d’employés de bureau (26 % [n = 31]), de médecins (19 % [n = 22]), d’infirmières et d’infirmiers praticiens (10 % [n = 12]), et d’adjoints au médecin (3 % [n = 4]). La plupart des cliniques fonctionnent à capacité maximale dont la médiane se situe à 300 consultations par mois (parts égales de consultations en personne et par téléphone). Les patients sont principalement aiguillés à la clinique par des médecins, et 47 (40 %) des 118 cliniques n’acceptent que les requêtes concernant des indications précises. La plupart des cliniques utilisent des algorithmes pour systématiquement évaluer et gérer les patients (87 % [103/118]) et des systèmes informatiques pour consigner les soins dispensés aux patients (86 % [101/118]). Une proportion semblable de cliniques utilisent des algorithmes pour calculer la dose de warfarine (82 % [84/103]) et effectuent des contrôles de qualité (82 % [97/118]). En cas d’un résultat clinique indésirable, 48 % des sondés (57/118) ont déclaré que la responsabilité serait partagée entre le médecin traitant et le personnel de la clinique alors que 37 % des sondés (44/118) ont répondu que seul le personnel de la clinique serait responsable.Conclusions : À la connaissance des auteurs, c’est la première fois qu’une enquête évalue les caractéristiques de fonctionnement des services de gestion de l’anticoagulation. Le fonctionnement des cliniques respecte généralement celui décrit sommairement dans les lignes directrices consensuelles. En nous aidant à mieux comprendre le fonctionnement quotidien de ces services, cette enquête nous permet d’émettre des recommandations de mécanismes visant à accroître l’efficacité des cliniques